1. Enteral and Parenteral Nutrition Support
Chapter 23
Enteral and Parenteral Nutrition Support

2. Enteral & parenteral nutrition

3. Enteral Nutrition Definition
Nutritional support via placement through the nose, esophagus, stomach, or intestines (duodenum or jejunum)
—Tube feedings
—Must have functioning GI tract
—IF THE GUT WORKS, USE IT!
—Exhaust all oral diet methods first.

4. Oral Supplements Between meals Added to foods
Added into liquids for medication pass by nursing
Enhances otherwise poor intake
May be needed by children or teens to support growth

5. Conditions That Require Other Nutrition Support
Enteral
—Impaired ingestion
—Inability to consume adequate nutrition orally
—Impaired digestion, absorption, metabolism
—Severe wasting or depressed growth
Parenteral
—Gastrointestinal incompetency
—Hypermetabolic state with poor enteral tolerance or accessibility

6. Conditions That Often Require Nutritional Support

7. Conditions That Often Require Nutritional Support –cont’d

8. Conditions That Often Require Nutritional Support –cont’d

9. Algorithm for Decisions
Modified and adapted from Gorman RC, Morris JB: Minimally invasive access to the gastrointestinal tract. In Rombeau JL,
Rolandelli RH, editors: Clinical nutrition: enteral and tube feeding, p 174, Philadelphia, 1997, WB Saunders; and Ali A et al:
Nutritional support services, Nutritional Support Algorithms, 8(7):13, July 1998.

10. Considerations in Enteral Nutrition
Applicable
Site placement
Formula selection
Nutritional/medical requirements
Rate and method of delivery
Tolerance

11. Formula Selection
The suitability of a feeding formula should be evaluated based on
Functional status of GI tract
Physical characteristics of formula (osmolality, fiber content, caloric density, viscosity)
Macronutrient ratios
Digestion and absorption capability of patient
Specific metabolic needs
Contribution of the feeding to fluid and electrolyte needs or restriction
Cost effectiveness

12. Enteral Formula Categories

13. Factors to Consider When Choosing an Enteral Formula

14. Enteral Access: Clinical Considerations
Duration of tube feeding
—Nasogastric or nasoenteric tube for short term
—Gastrostomy and jejunostomy tubes for long term
Placement of tube
—Gastric
—Small bowel

15. Placement Site Access (medical status)
Location (radiographic confirmation)
Duration
Tube measurements and durability
Adequacy of GI functioning

16. Enteral Tube Placement

17. Advantages—Enteral Nutrition
Intake easily/accurately monitored
Provides nutrition when oral is not possible or adequate
Costs less than parenteral nutrition
Supplies readily available
Reduces risks associated with disease state

18. More Advantages— Enteral Nutrition
Preserves gut integrity
Decreases likelihood of bacterial translocation
Preserves immunologic function of gut
Increased compliance with intake

19. Disadvantages—Enteral Nutrition
GI, metabolic, and mechanical complications—tube migration; increased risk of bacterial contamination; tube obstruction; pneumothorax
Costs more than oral diets
Less “palatable/normal”
Labor-intensive assessment, administration, tube patency and site care, monitoring

20. Complications of Enteral Feeding
Access problems (tube obstruction)
Administration problems (aspiration)
Gastrointestinal complications (diarrhea)
Metabolic complications (overhydration)

21. Aspiration Pneumonia Can result from enteral feeds High-risk patients
—Poor gag reflex
—Depressed mental status

22. Reducing Risk of Aspiration
Check gastric residuals if receiving gastric feeds
Elevate head of the bed >30 degrees during feedings
Postpyloric feeding
—Nasoenteric tube placement may require fluoroscopic visualization or endoscopic guidance
—Transgastric jejunostomy tube

23. Rate and Method of Delivery*
Bolus—300 to 400 ml rapid delivery via syringe several times daily
Intermittent─300 to 400 ml, 20 to 30 minutes, several times/day via gravity drip or syringe
Cyclic—via pump usually at night
Continuous—via gravity drip or infusion pump
*Determined by medical status, feeding route and volume, and nutritional goals

24. Consideration of Physical Properties of Enteral Formulas
Residue
Viscosity
—Size of tube is important
Osmolality: consider protein source
—Intact (do not affect osmolality)—soy isolates; sodium or calcium casein; lactalbumin
—Hydrolyzed (more particles)—peptides or free amino acids

25. Renal Solute Load Normal adult tolerance is 1200 to 1400 mOsm/L
Infants and renal patients may tolerate less

26. Lower Osmolality
Large (intact) proteins
Large starch molecules

27. Higher Osmolality
Hydrolyzed protein or amino acids
Disaccharides

28. Tolerance Signs and symptoms: —Consciousness —Respiratory distress
—Nausea, vomiting, diarrhea
—Constipation, cramps
—Aspiration
—Abdominal distention

29. Tolerance—cont’d Other signs and symptoms —Hydration —Labs
—Weight change
—Esophageal reflux
—Lactose/gluten intolerances
—Glucose fluctuations

30. How to Determine Energy and Protein
kcal/ml x ml given = kcal
% protein x kcal = kcal as protein
kcal as protein x 1 g/4 kcal = g protein
Example: Patient drinks 200 cc of a 15.3% protein product that has 1 kcal/ml
1 kcal/ml x 200 ml = 200 kcal
0.153 % protein x 200 kcal = 30.6 kcal
30.6 kcal x 1g protein/4 kcal = 7.65 g protein

31. Energy in Formulas 1 to 1.2 kcal/ml = usual concentration
2 kcal/ml = highest concentration

32. Protein From 4% to 26% of kcal is possible 14% to 16% of kcal is usual
18% to 26% of kcal—considered to be high-protein solution

33. Recommended Water Healthy adult: 1 ml/kcal or 35 ml/kg
Healthy infant: 1.5 ml/kcal or 150 ml/kg
Normal tube feeding: 1 kcal/ml; 80% to 85% water
Elderly: consider 25 ml/kg with renal, liver, or cardiac failure; or consider 35 ml/kg if history of dehydration

34. Sources of Fluid (“Free Water”)
Liquids
Water in food
Water from metabolism
With tube feeding, nurse will flush tube with water about 3 times daily—include this amount in estimated needs
—Example: “flush with 200 cc tid”

35. Administration: Feeding Rate
Continuous method = slow rate of 50 to 150 ml/hr for 12 to 24 hours
Intermittent method = 250 to 400 ml of feeding given in 5 to 8 feedings per 24 hours
Bolus method = may give 300 to 400 ml several time a day (“push” is not desired)

36. French Units—Tube Size
Diameter of feeding tube is measured in French units
1F = 33 mm diameter
Feeding tube sizes differ for formula types and administration techniques.

37. Examples of Special Formulas
Pediatrics
Low residue
High protein
Volume restriction
Diabetic
Pulmonary/COPD

38. Enteral Nutrition Monitoring

39. Routes of Parenteral Nutrition
Central access
—TPN both long- and short-term placement
Peripheral or PPN
—New catheters allow longer support via this method limited to 800 to 900 mOsm/kg due to thrombophlebitis
<2000 kcal required or <10 days

40. PPN vs. TPN Kcal required (10% dextrose max. PPN conc.)
Fluid tolerance
Osmolarity
Duration
Central line contraindicated

41. Venous Sites from Which the Superior Vena Cava May Be Accessed

42. Advantages—Parenteral Nutrition
Provides nutrients when less than 2 to 3 feet of small intestine remains
Allows nutrition support when GI intolerance prevents oral or enteral support

43. Indications for Total Parenteral Nutrition
GI non functioning
NPO >5 days
GI fistula
Acute pancreatitis
Short bowel syndrome
Malnutrition with >10% to 15 % weight loss
Nutritional needs not met; patient refuses food

44. Contraindications GI tract works Terminally ill
Only needed briefly (<14 days)

45. Calculating Nutrient Needs
Avoid excess kcal (> 40 kcal/kg)
Adults
kcal/kg BW
Obese—use desired BMI range or an adjusted factor

46. Adjusted Body Weight Adjusted IBW for obesity Female:
([actual weight – IBW] x 0.32) + IBW
Male:
([actual weight – IBW] x 0.38) + IBW

47. Parenteral Components
Carbohydrate
glucose or dextrose monohydrate
3.4 kcal/g
Amino acids
3, 3.5, 5, 7, 8.5, 10% solutions
Fat
10% emulsions = 1.1 kcal/ml
20% emulsions = 2 kcal/ml

49. Protein Requirements
1.2 to 1.5 g protein/kg IBW mild or moderate stress
2.5 g protein/kg IBW burns or severe trauma

50. Carbohydrate Requirements
Max g/kg BW/hr
Excess glucose causes:
Increased minute ventilation
Increased CO2 production
Increased RQ
Increased O2 consumption
Lipogenesis and liver problems

51. Lipid Requirements
4% to 10% kcals given as lipid meets EFA requirements; or 2% to 4% kcals given as lineoleic acid
Usual range 25% to 35% max. 60% of kcal or 2.5 g fat/kg

52. Other Requirements Fluid—30 to 50 ml/kg Electrolytes
Use acetate or chloride forms
to manage acidosis or alkalosis
Vitamins
Trace elements

53. Calculating the Osmolarity of a Parenteral Nutrition Solution
1. Multiply the grams of dextrose per liter by 5. Example: 50 g of dextrose x 5 = 250 mOsm/L
2. Multiply the grams of protein per liter by 10. Example: 30 g of protein x 10 = 300 mOsm/L
3. Fat is isotonic and does not contribute to osmolarity.
4. Electrolytes further add to osmolarity. Total osmolarity = = 500 mOsm/L

54. Compounding Methods
Total nutrient admixture of amino acids, glucose, additives
3-in-1 solution of lipid, amino acids, glucose, additives

55. Administration Start slowly (1 L 1st day; 2 L 2nd day)
Stop slowly (reduce rate by half every 1 to 2 hrs or switch to dextrose IV)
Cyclic give 12 to 18 hours per day

56. Monitoring and Complications
Infection
Hemodynamic stability
Catheter care
Refeeding syndrome

57. Refeeding Syndrome Hypophosphatemia Hyperglycemia Fluid retention
Cardiac arrest

58. Monitor Weight (daily)
Blood Daily Electrolytes (Na+, K+, Cl-) Glucose Acid-base status 3 times/week BUN Ca+, P Plasma transaminases

59. Monitor—cont’d
Blood Twice/week Ammonia Mg Plasma transaminases Weekly Hgb Prothrombin time Zn Cu Triglycerides

60. Monitor—cont’d
Urine: Glucose and ketones (4-6/day) Specific gravity or osmolarity (2-4/day) Urinary urea nitrogen (weekly)
Other: Volume infusate (daily) Oral intake (daily) if applicable Urinary output (daily) Activity, temperature, respiration (daily) WBC and differential (as needed) Cultures (as needed)

61. Problems PPN Site irritation
TPN 1. Catheter sepsis 2. Placement problems 3. Metabolic

62. Pediatric
Energy Infant 50 to 60 kcal/kg/day maintenance 70 to 120 kcal/kg/day growth
Child >1yr BEE 1to 8 yrs 70 to 100 kcal/kg/day 8 to 12 yrs 60 to 75 kcal/kg/day to 18 yrs 45 to 60 kcal/kg/day Injury factors mild stress nutritional depletion high stress

63. Pediatric—cont’d
Protein: Infant to 4 g/kg/day <1500 g weight to 2.5 g/kg/day 0 to 12 months
normal weight
Child >1 year to 8 years 1.5 to 2.0 g/kg/day to 15 years 1.0 to 1.5 g/kg/day

64. Pediatric—cont’d
Carbohydrate Infant preterm: to 6 mg/kg/minute begin rate Term infants: to 9 mg/kg/minute begin rate
Fat Infants: to 1.0 g/kg/day min for EFA needs to 3 g/kg/day max
Vitamins and minerals: See tables in textbook

65. Pediatric—cont’d
Fluid and electrolytes Infant: LBW 125 to 150 ml/kg/day 2 to 4 mmol/kg/day for electrolytes
Other infants and children

66. Document in Chart Type of feeding formula and tube
Method (bolus, drip, pump)
Rate and water flush
Intake energy and protein
Tolerance, complications, and corrective actions
Patient education

67. For more information see chapter 7
Walker and Roger